Provider Demographics
NPI:1063256634
Name:METHOD 4 CHANGE LLC
Entity type:Organization
Organization Name:METHOD 4 CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:RISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-330-2442
Mailing Address - Street 1:PO BOX 4040
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92628-4040
Mailing Address - Country:US
Mailing Address - Phone:714-330-2442
Mailing Address - Fax:
Practice Address - Street 1:16092 FELTHAM CIR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-7620
Practice Address - Country:US
Practice Address - Phone:714-330-2442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-19
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility